WHO recommendations on antenatal care for a positive pregnancy experience

Additional considerations
• nEvidence from subgroups tended to be consistent
with the overall findings for the main outcomes.
More details can be found in the Web supplement
(EB Table A.2.1).
Values
Please see “Women’s values” in section 3.A:
Background (p. 15).
Resources
Daily iron and folic acid supplements are relatively
low cost, at less than 1 United States dollar (US$ 1)
per pregnant woman (27).
Equity
Iron deficiency and parasitic infections are more
common in LMICs and disadvantaged populations.
Poor, rural and least-educated populations also
experience the highest maternal, infant and child
mortality (29). Increasing coverage of effective
nutritional interventions to prevent anaemia,
particularly among disadvantaged populations,
might help to address maternal and newborn health
inequalities.
Acceptability
Qualitative evidence suggests that the availability of
iron supplements may actively encourage women to
engage with ANC providers (low confidence in the
evidence) (22). However, where there are additional
costs associated with supplementation or where
the supplements may be unavailable (because of
resource constraints) women are less likely to engage
with ANC services (high confidence in the evidence).
Lower doses of iron may be associated with fewer
side-effects and therefore may be more acceptable to
women than higher doses.
Feasibility
Qualitative evidence about the views of health-care
providers suggests that resource constraints, both in
terms of the availability of the supplements and the
lack of suitably trained staff to deliver them, may limit
implementation (high confidence in the evidence)
(45).
A.2.2: Intermittent iron and folic acid supplements
RECOMMENDATION A.2.2: Intermittent oral iron and folic acid supplementation with 120 mg
of elemental iron a and 2800 µg (2.8 mg) of folic acid once weekly is recommended for pregnant
women to improve maternal and neonatal outcomes if daily iron is not acceptable due to sideeffects,
and in populations with an anaemia prevalence among pregnant women of less than
20%. (Context-specific recommendation)
Remarks
• This recommendation supersedes the previous <strong>WHO</strong> recommendation in the 2012 Guideline: intermittent
iron and folic acid supplementation in non-anaemic pregnant women (55) and should be considered
alongside Recommendation A.1.1.
• In general, anaemia prevalence of less than 20% is classified as a mild public health problem (33).
• Before commencing intermittent iron supplementation, accurate measurement of maternal blood Hb
concentrations is needed to confirm the absence of anaemia. Therefore, this recommendation may require
a strong health system to facilitate accurate Hb measurement and to monitor anaemia status throughout
pregnancy.
• If a woman is diagnosed with anaemia (Hb < 110 g/L) during ANC, she should be given 120 mg of
elemental iron and 400 µg (0.4 mg) of folic acid daily until her Hb concentration rises to normal (Hb 110
g/L or higher) (34, 51). Thereafter, she can continue with the standard daily antenatal iron and folic acid
dose (or the intermittent regimen if daily iron is not acceptable due to side-effects) to prevent recurrence
of anaemia.
• Stakeholders may need to consider ways of reminding pregnant women to take their supplements on an
intermittent basis and of assisting them to manage associated side-effects.
a The equivalent of 120 mg of elemental iron is 600 mg of ferrous sulfate hepahydrate, 360 mg of ferrous fumarate or 1000 mg of ferrous gluconate.
Chapter 3. Evidence and <strong>recommendations</strong> 25